=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972657393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDTOWN PRIMARY CARE ASSOCIATES MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 10/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 970 RESERVE DR SUITE 149
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-1376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-290-8672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 970 RESERVE DR SUITE 149
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95678-1376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-290-8672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MS. PAMELA J MCDONALD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-290-8672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G42424
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------